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Saturday, July 28, 2018

BioMed Sector: the Bleeding Edge

My wife alerted me to this.

"What you don't know, can hurt you. From the Academy Award® nominated filmmakers Kirby Dick and Amy Ziering (The Invisible War, The Hunting Ground) comes a groundbreaking investigation into the crimes of Big Medical. America has the most technologically advanced health care system in the world, yet medical interventions have become the third leading cause of death, and the overwhelming majority of high-risk implanted devices never require a single clinical trial."
Film Review: ‘The Bleeding Edge’
Kirby Dick's disturbingly powerful exposé of the medical-device industry nails a corporatized America that has stopped taking care of its citizens.

If you watch enough passionate muckraking social-justice documentaries, or simply listen to the news every day, you may feel like you’ve lost the capacity to be shocked. But “The Bleeding Edge,” Kirby Dick’s disturbingly powerful and important documentary about the medical-device industry, contains a line near the end that truly shocked me, because it defines, with a word (in fact, three little letters), what’s happened to America.

The movie is about an industry that now generates revenues of $300 billion a year by producing and marketing the highly sophisticated utensils and apparatuses that get implanted into people’s bodies. (Over the last decade, 70 million Americans have been outfitted with internal medical devices.) It’s also about the scandalous and clandestine inhumanity of those companies. There are, of course, many devices that save lives and vastly uplift people’s daily welfare: pacemakers, hip replacements, cornea transplants.

The film doesn’t deny any of this; it never paints its indictment with a broad brush. But it focuses on a handful of devices that have caused toxic levels of harm to the trusting victims who’ve used them, and the scandal — which is ongoing — is that the devices were never properly tested. In essence, the corporations put them out there and said, “What the hell, let’s give this a try!” The people who used the devices became human guinea pigs (just like the women who took thalidomide in the late 1950s), and when they began to develop symptoms of harm, they had no idea what was happening to them. Even when they started to figure out the source of their symptoms, there was little or no recourse and (in many cases) no way to reverse the damage…
Interesting. About a month hence I will be the SAVR px recipient of a biomedical device, a prosthetic bovine aortic valve.

I recently finished watching the moving HBO documentary on the late Robin Williams ("Come inside my mind"). I'd not been aware that he'd had a SAVR:

What a terrible loss.

I never got to meet him. That would have been so cool. We have a mutual connection.

We have NetFlix here, will have to pull up The Bleeding Edge and watch it. Stay tuned.


We pulled The Bleeding Edge up on NetFlix and watched it in its entirety in rapt attention. It is a must-see.

Compelling. Infuriating.

Again, a must-see documentary. Below, from the website:
The Facts in The Bleeding Edge

The medical device industry has responded to the malfeasance exposed in our investigative documentary The Bleeding Edge.

Here are the facts:

The facts set forth in The Bleeding Edge are accurate and have been rigorously vetted by extensive research and multiple experts.

Bayer claims the portrayal of its harmful birth control device Essure in The Bleeding Edge “lacks scientific support” and is “inaccurate and misleading.” These claims are false.

The truth is that Essure was approved under an “expedited review” without randomized, nonblinded studies or a comparator group. These studies followed most participants for only 18 months, even though Essure is supposed to remain implanted for a woman’s lifetime. Some of the patient forms in the Essure studies were altered to reflect a more positive outcome than what was reported by the patient. Conceptus, the original manufacturer of Essure purchased by Bayer, hid more than 32,000 adverse events regarding Essure from the FDA.

Bayer’s attacks on three of the experts in The Bleeding Edge are without substance. There are no conflicts of interest regarding any of the experts in our film.

Dr. Diana Zuckerman is president of the non-profit National Center for Health Research (NCRH.) As an expert witness discussing her survey of Essure patients, she requested that the plaintiff’s attorney pay $375 to the NCRH. This represents no conflict because she says nothing about Essure in the film. Dr. Zuckerman has been quoted in the New York Times, the Washington Post and other media describing the need for well-designed, long-term research on Essure.

Dr. Julio Novoa is an experienced OB-GYN who surgically removes Essure from women who have been harmed by the device. For Bayer to suggest that he has “a financial interest in recommending the removal of the product” because he is being paid for doing his job is both cynical and false. Madris Tomes, a former public health analyst for the FDA, provides FDA public data and trends of adverse event reports to clients. Tomes has provided data expertise to the Essure Problems Facebook group pro bono.

On July 20, one week before The Bleeding Edge was released on Netflix, Bayer announced it would stop selling Essure after 2018.

In response to the film, Johnson & Johnson stated “providing safe and effective products is always our top priority.” This is contradicted by the fact that they released cobalt metal-on-metal hips as well as pelvic mesh despite knowing that there were significant safety risks with both.

Court records show that in 1995 a scientist from DePuy, whose parent company is J&J, warned about the dangers of their cobalt metal hip. After it was put on the market, surgeons, researchers and health officials repeatedly informed J&J that their hip device was harming patients, but it wasn’t until 2010 that J&J finally recalled the product, after it harmed tens of thousands of people.

Additionally, court records show that J&J also knew their pelvic mesh would injure women, but J&J chose to put the device on the market anyway. There are now tens of thousands of lawsuits filed against them by women harmed by mesh.

In response to the film, the FDA stated, “Often the true benefit-risk profile of a device cannot be fully understood until it can be evaluated when used in routine clinical practice.” This is far too late. To protect Americans, the FDA must establish that a device is safe before it is put on the market.
The FDA claims that it has taken “many steps” in recent years regarding Essure, but the FDA never took the most important step: recalling this flawed and dangerous device from the market in the U.S., especially after it had been taken off the market in the rest of the world.
The FDA, Bayer, Johnson & Johnson all declined to be interviewed for the film.

From The Union of Concerned Scientists:
Drug and Medical Device Companies Have Outsized Influence on FDA
$700 million in lobbying buys significant access

As Congress decides the influence that pharmaceutical, biotech and medical device companies should have over the Food and Drug Administration (FDA), industry spends big.

Data compiled by the Center for Responsive Politics and commissioned by the Union of Concerned Scientists show that between 2009 and 2011, prescription drug, biotechnology and medical device companies spent more than $700 million lobbying Congress and the Obama administration.

That’s a lot of money. By comparison, the insurance industry spent $480 million in the same period. Drug companies alone spent more than $487 million on lobbying during the three-year period; biotechnology and medical device companies spent $126 million and $86 million, respectively.

Over the same period, elected officials on a House subcommittee and a Senate committee with oversight over FDA received nearly $6.3 million in campaign contributions from these industries. Donations went to both Republicans and Democrats.

Explore the major findings from our investigation and see all of the data we relied upon…
In a recent book review post, "Overcharged: paying for health care," we looked at U.S. exorbitant cost issues. Here's an excerpt from the book:
“How Could a Medical Device Be So Well Accepted Without Any Evidence of Efficacy?” We offer three reasons. First, doctors had a theory suggesting that the filters should work. Second, once the practice of using filters gained a following, doctors simply “assumed that there was strong evidence for their use.” Why else would so many doctors have put so many filters in so many patients? Third, Medicare, Medicaid, and other payers covered the procedures. In hospital settings, Medicare paid $3,300 for filter insertion, $2,600 for filter repositioning, and $2,600 for filter removal. When these procedures were performed in a doctor’s office, the fees were $2,800, $1,800, and $1,750, respectively. Treatment patterns got well ahead of the science. When the science finally caught up, there was a large financial incentive not to reverse course.

AUCs and other professional guidelines are pointless unless they limit practitioners’ discretion and prevent them from recommending aggressive treatments too often. The tendency to overprescribe reflects a confluence of factors: physicians’ strong desire to help, their belief in the efficacy of their tools, and, of course, the strong financial incentive to perform procedures. As Dr. Redberg put it when discussing the epidemic of overstenting, “It’s like asking a barber if you need a haircut. To an interventional cardiologist, stents are good for almost everyone.”

Charles Silver & David A. Hyman. Overcharged: Why Americans Pay Too Much for Health Care (Kindle Locations 2340-2351). CATO Institute.
Interesting. BTW, searching "FDA" in the book netted 87 hits, nearly all of the textual references using the acronym critical.


THE Health IT event of the year.

Saw news that Alan Alda has gone public with his having Parkinson's. He remains unfazed, and continues with great work (that I have to sheepishly admit to not having been aware of).

"The Alan Alda Center for Communicating Science empowers scientists and health professionals to communicate complex topics in clear, vivid, and engaging ways; leading to improved understanding by the public, media, patients, elected officials, and others outside of their own discipline..."
I registered. This is important stuff.

More in a forthcoming post. For now, relatedly, see my prior post "A case for interdisciplinary science."

More to come...

Thursday, July 26, 2018

Daniel Kraft on AI and early dx detection

I've cited Daniel Kraft before, and seen him at many Health 2.0 events.

2017 Conference

 A Heavy Hitter. Pediatric oncologist and cutting-edge techie.

Rob Reid has interviewed him for ARS Technica.
"Daniel founded and runs the Exponential Medicine Conference, which is one of the largest cross-disciplinary gatherings of life science researchers and innovators. He also founded and runs the medical faculty at Singularity University—an academic institution so quirky, it could only have sprouted up from Silicon Valley’s soil.

When Daniel does a presentation, he's the opposite of that speaker we've all seen—the one who has to do everything possible to pad their words and slides to fill a time slot. With Daniel, I always sense that there's an entire presentation lurking behind every slide that he puts on the screen. He just has so much surface area from his two highly complementary jobs, which connect him to hundreds of startups and researchers every year. Daniel is particularly deep in medical devices, ranging from consumer-grade gear to tools that only turn up in research hospitals. And as an oncologist, he’s of course deeply informed about cancer…"

Enjoy. (BTW, correction: two episodes, not three.)

Article interview links here and here (replete with transcripts).


Ran across another interesting book, cited over at Naked Capitalism.

The emergence of organisms who are conscious of the direction of evolution is one of the most important steps in the evolution of life on any planet. Once organisms discover the direction of evolution, they can use it to guide their own evolution. If they know where evolution is going, they can work out what will produce success in the future, and use this to plan how they will evolve. Living things can evolve without having any knowledge of the direction of evolution. The diversity and complexity of life on earth is testimony to that. Organisms can try to deal with the future by blindly making changes to themselves or their offspring and seeing how the changes work out in practice. But this takes a lot of costly trial-and-error, particularly when the future is complex or changes rapidly. It is a bit like trying to drive a car through peak-hour traffic blindfolded. It will not be a winning strategy for organisms whose competitors can predict future events and use this to evolve more effectively.

The alternative is for organisms to guide their evolution by forming a picture of how evolution is likely to unfold in the future. They can try to find trends and patterns in this evolution that might impact on their future chances of survival. They can then use these patterns to order to see how they must change themselves and the way they are organized in order to continue to be successful.

On this planet, the organism that appears likely to take this significant evolutionary step is us. Our growing understanding of evolution is providing us with the knowledge that will enable us to see that there are large-scale patterns in the evolution of life. And it is a short step from this to recognising the evolutionary significance of using these patterns to guide our own evolution. But this significant step will not be possible until we have developed a comprehensive understanding of the direction of evolution and of its implications for humanity. The development of this theory will itself be an important step in our evolution…

Stewart, John. Evolution's Arrow: the direction of evolution and the future of humanity (Kindle Locations 91-109). The Chapman Press. Kindle Edition.
Yeah. But it behooves us to not conflate biological evolution (the s-l-o-w stochastic "random walk"; Gould's "Drunkard's Walk") with "cultural evolution" (which is Lamarckist, and embodies exponential improvements in technologies).


 Monday August 20th, my decrepit aortic valve comes out. Whew. As I noted in a prior post,
...a highly respected and experienced local cardiac surgeon and his team will sedate and anesthetize me, render me deeply unconscious, emplace a breathing tube in my throat, slice open my chest, spread out my rib cage, stop my heartbeat, put me on a heart-lung machine, cut my heart open, remove my seriously stenotic aortic valve, replace it with a sutured-in prosthetic (pig or bovine tissue) valve, close the heart back up and re-start it, close my chest back up, and send me off to Recovery.

One hopes.
I've put this off as long as possible, given Danielle's illness. Tomorrow will be both her 48th birthday and precisely three months since she died.


Interesting excerpt from a STATnews article:
Physicians aren’t ‘burning out.’ They’re suffering from moral injury

The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury…

In an increasingly business-oriented and profit-driven health care environment, physicians must consider a multitude of factors other than their patients’ best interests when deciding on treatment. Financial considerations — of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself — lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.

Patient satisfaction scores and provider rating and review sites can give patients more information about choosing a physician, a hospital, or a health care system. But they can also silence physicians from providing necessary but unwelcome advice to patients, and can lead to over-treatment to keep some patients satisfied. Business practices may drive providers to refer patients within their own systems, even knowing that doing so will delay care or that their equipment or staffing is sub-optimal.

Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of “death by a thousand cuts.” Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care...
I will let slide for now the obligatory shot at EHRs.


My iPhone wallpaper. Today is my late daughter's 48th birthday. We shot this "selfie" back in March the day after she returned from the Kaiser Antioch ER the prior night, where she'd decided to commence home hospice care.


More to come...

Monday, July 23, 2018

Are we "Overcharged" for health care? Will it get even worse?

Recall my recent post citing this book:

Saw some additional stuff of interest via NPR. "Health Insurers Are Vacuuming Up Details About You — And It Could Raise Your Rates."

Insurance companies and data brokers are more and more often using your personal information from social media to predict your health care costs. And they are exploring ways to use that data to determine the rates that you will pay. That's the finding of a new investigation by the nonprofit newsroom ProPublica. Joining us now from our New York studio is their reporter Marshall Allen.
Good morning, Marshall.


Good morning.


All right - so you found that insurance companies are using stuff that we post on Facebook and Twitter and Instagram. What exactly are they gathering?


Well, they're gathering things about your race, your ethnicity, your education level, your TV-watching habits, your marital status, your net worth. They're trying to gather everything they can about us to, in some cases, try and predict what it will cost us to be cared for.


What does me being married or not being married have to do with health insurance?


Well, there's a lot of studies now about social determinants of health - that's kind of the jargon they use to describe it - that show that a lot of a person's health does come from social and economic conditions that they're raised in. And you can kind of see, as a group, how this would happen. So for instance, one of the companies would say, if you're a woman who's recently changed your name, which is something they can tell from public records, maybe you're newly married and so you're about to get pregnant. Or perhaps you are recently divorced and so you're stressed out. And both of those things could lead to higher health care costs.


They are making a heck of a lot of assumptions here. How accurate is this as a method of predicting how healthy people are or are not?


Well, that's what I kept asking them. You know, I had a lot of conversations with a company called LexisNexis Risk Solutions. They're one of the main data brokers who are trafficking in this kind of information. And what they said they've done is that they've linked the personal attributes that we all have to claims data from our medical care costs. And then they use that to draw inferences, which they say are accurate. Now, they haven't done any studies that are available about this. They don't put out any methodology, so we can't really tell how they're doing it. It is a black box. But they say that it is predictive.

I want to point out one other important detail. I wasn't able to nail down whether they're actually using this information to price our health plans right now for a process called underwriting. They're definitely using it to measure our costs and estimate our costs. But what the insurance industry says they're doing is they're using it for case management so they can offer services to help sick people stay healthier.


OK. So they're saying it is a benevolent move on their part.


That's exactly right. They say that this allows them to offer better services for patients.


Is there an argument here that this is exactly what insurance companies do? They get all the data they can on you, and then they figure out how much of a risk you are. I'm just trying to figure out why this is notable. It sort of seems like insurance companies were destined to do this once they knew they could.


Well, it does seem that way, and I think that's a really reasonable question to ask. And you know, they do need to properly assess the risk of each of us so that they can properly price plans so they can know how much we might cost. I mean, that's an important part of the process.

But one thing is this is happening with no public scrutiny. And this is also happening in a way where insurance companies could use the information to discriminate. And that's not something I nailed down with my reporting, but I talked to a lot of experts about how insurance companies do what's called cherry-picking. And by that, I mean they will try and find the healthiest, lowest-cost people and offer them health insurance. And they will try and avoid high-cost health conditions so that they don't have more risk. The Affordable Care Act has made it more difficult to blatantly discriminate, but experts say the discrimination still exists and that this type of information could be used for that purpose.


Marshall Allen is a reporter with ProPublica. Marshall, thank you so much for joining us.


Thank you.
I did a 5-year stint in subprime risk modeling and management (2000 - 2005). Back then we had applicant and customer data elements in our own data warehouse we could not legally use for vetting current and prospective customer risks. Those restraints seem to be long-gone.
[ I wrote all of the bank's White Papers. See my Proprietary Risk Model Scorecard Suite Development paper (large pdf). ]
apropos, see my prior post "(404)^n, the upshot of dirty data." And, my post "The old internet of data, the new internet of things and "Big Data," and the evolving internet of YOU."


From Down Under.
Why Healthy People Should Subsidize the Sick
An introduction to healthcare economics
If there’s one thing that we can all agree on, it’s that healthcare should be cheaper. It’s not that healthcare is overpriced — although if you live in the U.S. you’re probably paying double anyone else in the world — but that it’s a significant cost that takes up a huge portion of our budget and it would be really nice if it were less expensive.

Also, it’s extremely overpriced…
Interesting argument. Will be much unloved over at The CATO Institute.

More to come...

Saturday, July 21, 2018

A case for interdisciplinary science

Got my latest hardcopy issue of Science Magazine. Of particular interest:

Conversations spark connections as scientists search for inspiration in other fields

If you knocked on Heaven’s door, and God greeted you, what question would you ask? What is the nature of human consciousness, and how can it be expanded? Where does the Universe begin and end? What is time, and why isn’t it constant? What causes deviance? And further still, if you received an answer, could you decipher it? Or would the answer only be a clue leading to the next clue?

The Most Unknown, a documentary film in the Simons Foundation Science Sandbox series, takes the viewer on a fantastical journey of nine scientists as they intrepidly knock on Heaven’s door. Each asks a profound question in a different way. But all are making a difference in how science explains the universe, the world we live in, and the worlds within us.

Although the filmmaker, Ian Cheney, is not a scientist, he makes a point that is now well documented scientifically: Scientists from different disciplines who immerse themselves in one another’s work and exchange ideas solve the hardest problems…

Woven into the film’s electrifying tapestry of ideas, persons, and places is the story of the hard work of science. Great discovery, we see, comes part and parcel with emotional frustration and disappointment, unusual hours that buck circadian rhythms, tight spaces, cold water, and dark places.

In The Most Unknown, Cheney connects apparently disparate journeys of discovery, illustrating where interdisciplinary teamwork can fill in a scientist’s blind spots. When seen through this lens, science can be viewed as a big import-export business of ideas. Conventional, well-understood ideas in one area, when brought into another scientific domain, are suddenly seen in a new light.

Newton’s observations that “standing on the shoulders of giants” is key to scientific discovery may only have been half right. As documented in The Most Unknown, scientists also have much to learn from their contemporaries.
Indeed. Can't wait to see this.

"The Most Unknown is an epic documentary film that sends nine scientists to extraordinary parts of the world to uncover unexpected answers to some of humanity’s biggest questions. How did life begin? What is time? What is consciousness? How much do we really know?

By introducing researchers from diverse backgrounds for the first time, then dropping them into new, immersive field work they previously hadn’t tackled, the film reveals the true potential of interdisciplinary collaboration, pushing the boundaries of how science storytelling is approached. What emerges is a deeply human trip to the foundations of discovery and a powerful reminder that the unanswered questions are the most crucial ones to pose.

Directed by Emmy-nominated and Peabody Award-winning filmmaker Ian Cheney (The Search for General Tso, The City Dark) and advised by world-renowned filmmaker Werner Herzog (Fitzcarraldo, Aguirre, The Wrath of God, Grizzly Man), The Most Unknown is an ambitious look at a side of science never before shown on screen. The film was made possible by a grant from Science Sandbox, a Simons Foundation initiative dedicated to engaging everyone with the process of science."
From the documentary info site at MOTHERBOARD:
In a world where the knowledge we gain from basic research faces a variety of threats ranging from apathy to outright antagonism, how do we make people care about science? For one, we can start with asking scientists why they're doing the work in the first place.

We're pleased to share the first trailer for Motherboard's first feature-length documentary, titled "The Most Unknown," which explores some of the biggest questions in science: What is dark matter? What is consciousness? Where did life come from? Is there life elsewhere in the universe?
Among other germane topics, this goes to themes in this book I cited earlier:

Another relevant prior citation comes to mind:

We must also recall the late Hans Gosling's new book "Factfulness." See also my citation of the book "The Silo Effect." And, my recent post "STEMM should get HACD."

Finally for now, my January 2017 post "I am not a scientist."

More to come...

Thursday, July 19, 2018

Indu Speaks

Dear friends and family, I’m thrilled to share that I was selected as an Aspen Fellow to immerse myself in the examination of leadership and to apply my learnings in to improve health and healthcare in the US. I'm daunted and honored and welcome conversations with all of you to take this task forward!

I’ve had a funny career, and this past year gave me a chance to reflect and reset. I launched not just to archive my work over the past 10+ years but also to explain to people, once and for all, what I do for a living! Here’s to all the oddballs who freeze when they can’t answer: fireman or policeman, doctor or lawyer when asked by their son’s first grade classmates what their job is (true story!). If there’s anything that the joy of speaking, writing and convening has taught me, it’s that no single one of us has the answer. But we can ask hard questions, listen deeply and then experiment according to our understanding. Rinse, repeat. And that makes and will always make a difference.

Thank you for your friendship and support, and sharing in a community of the curious as we figure this world out and hopefully leave it a touch better in some corners in whatever way we can.

One of my shots from the 2017 Health 2.0 Conference
" single one of us has the answer. But we can ask hard questions, listen deeply and then experiment according to our understanding. Rinse, repeat. And that makes and will always make a difference."
Indeed. This old "oddball" washed-up guitar player / techie could not agree more.

I have long called Indu "the most cheerful person in all of health care."


THE Health IT event of the year.

More to come...

Wednesday, July 18, 2018

The potential promise and peril of reading your full genome

Interesting ARS Technica series underway.
"The cost of full-genome sequencing is falling so quickly and the actionable insights it can reveal are growing fast enough that this data will eventually be as widely collected as cholesterol levels (perhaps within a decade or so)."


"Actionable insights." That's the key.  From Episode Two:
"A tiny fraction of people might indeed make discoveries that are both horrible and unactionable. A larger fraction could suffer anguish from the sheer ambiguity of what’s divulged. After carefully studying both the psychology and consequences of these situations, Robert is fully convinced that personal genetic information should be made available to any adult who seeks it, after being soundly apprised of the ramifications."
ARS Technica is routinely one of my daily priority stops. Always good stuff there. I'll embed the 3rd episode once it's available.

"Today we open with a heartening story about an infant who went through one of Robert’s studies and may have picked up fifteen IQ points as a direct result (this is neither a metaphor nor an exaggeration)! It’s an early—and perhaps even the first—hard example of how full-genome sequencing at birth could one day save innumerable lives and preclude untold human suffering."

Host Rob Reid on Twitter. And, Robert C. Green, MD, MPH, interviewee. See also here.
(BTW, there are links to the transcripts at the Ars Technica site.)
From one of their papers (pdf):
Short-term costs of integrating whole-genome sequencing into primary care and cardiology settings: a pilot randomized trial

Whole-genome sequencing (WGS) can facilitate molecular diagnoses and identify genetic variants to characterize disease risks, tailor medications, screen for recessive traits, and more. Dramatic improvements in its cost, speed, and capabilities are fueling expectations that WGS will become an important part of everyday patient care, and some commentators hope that it will streamline diagnoses and enhance disease prevention. Early evidence is promising, but there are concerns that WGS may also initiate a cascade of confirmatory testing and ongoing screening that greatly increases health-care expenditures. Empirical data to inform the discussion are sparse…
Cost-benefit considerations?

I've had a recurrent go at various aspects of genomics issues here.This topic also goes to "Information Ethics."

"We close by discussing a massively ambitious government initiative that’s just gathering steam called “All of Us.” If it delivers on its goals (and doesn’t turn into a DMV-like debacle), it could transform our understanding of health, aging, and disease innumerable times more than the renowned Framingham Heart Study..."
Yeah, that goes to another prior post of mine, "All of Us?" "Personalized Medicine?"


I finished listening intently to all three Reid-Green podcasts. Highly, highly recommended. Well worth your time. About 100 minutes total interview program. They pretty much cover the broad and deep gamut of tech, economic, sociopolitical, and and thorny ethical issues that bear on while genome sequencing. This stuff is coming to the primary care exam room fairly soon, and we are seriously advised to understand what it entails. to wit, from the episode two transcript:
...Think about that, five thousand genes, all sorts of categories we've been talking about, dominant, recessive, pharmacogenomics, and some other things, we put on a one page report for a doctor. 'Cause you know what? They don't wanna learn the discipline of genomics, they just wanna know what's useful to their patient.
And these are primary care doctors?
Primary care doctors.
This is their family doctor, their internist, the person they go to first when they have a sniffle or they're not sure what's going on, so these are not geneticists or genetic counselors, these are the people who will be dealing with this information for hundreds of millions of us real soon now.
And it sounds absurd when you think about it, 'cause genomics is so complicated, you need your specialist. But look, primary care doctors interpret x-rays without being nuclear physicists, they interpret chemistry reports without being chemists, it's really a matter of packaging this and directing them with sufficient clinical support that if they get confused they have somebody to turn to. That's a kind of heretical idea honestly, we have said, "Genetics is so complicated and so scary, only the geneticists should hold onto it", it doesn't make me very popular among many of my confreres in genetics because what I'm saying is, "You know what guys, this is too big for our small specialty, this is something that every doctor's gonna have to deal with."
So we created a one page report, and then we didn't just throw it out there, we put all sorts of safety nets in place. This taping reminds me, we audio taped every interaction between that primary care doctor and that patient, and we transcribed it, and we examined it for errors. We followed their electronic health record in real time to make sure they weren't even ordering something inappropriate… 


THE Health IT event of the year.
I started covering it in 2012.

See their selected 2017 Conference videos. I was always sitting front-row center.

More to come...

Monday, July 16, 2018

STEMM should get HACD

From my hardcopy Science Magazine that just arrived. "STEMM," Science, Technology. Engineering, Math, Medicine. "HACD," Humanities, Arts, Crafts, Design.
Incorporating humanities, arts, crafts, and design into curricula makes better scientists

If you’ve ever had a medical procedure, chances are you benefited from the arts. The stethoscope was invented by a French flautist/physician named René Laennec who recorded his first observations of heart sounds in musical notation. The suturing techniques used for organ transplants were adapted from lacemaking by another Frenchman, Nobel laureate Alexis Carrel. The methods (and some of the tools) required to perform the first open-heart surgeries were invented by an African-American innovator named Vivien Thomas, whose formal training was as a master carpenter.

But perhaps you’re more of a technology lover. The idea of instantaneous electronic communication was the invention of one of America’s most famous artists, Samuel Morse, who built his first telegraph on a canvas stretcher. Actress Hedy Lamarr collaborated with the avant-garde composer George Antheil to invent modern encryption of electronic messages. Even the electronic chips that run our phones and computers are fabricated using artistic inventions: etching, silk-screen printing, and photolithography.

On 7 May 2018, the Board on Higher Education and Workforce of the U.S. National Academies of Sciences, Engineering, and Medicine (NASEM) released a report recommending that humanities, arts, crafts, and design (HACD) practices be integrated with science, technology, engineering, mathematics, and medicine (STEMM) in college and post-graduate curricula (1). The motivation for the study is the growing divide in American educational systems between traditional liberal arts curricula and job-related specialization. “Ironically,” the report notes, “as this movement toward narrower, disciplinary education has progressed inexorably, many employers—even, and, in fact, especially in ‘high tech’ areas—have emphasized that learning outcomes associated with integrated education, such as critical thinking, communication, teamwork, and abilities for lifelong learning, are more, not less, desirable.”

Because the ecology of education is so complex, the report concludes that there is no one, or best, way to integrate arts and humanities with STEMM learning, nor any single type of pedagogical experiment or set of data that proves incontrovertibly that integration is the definitive answer to improved job preparedness. Nonetheless, a preponderance of evidence converges on the conclusion that incorporating HACD into STEMM pedagogies can improve STEMM performance…
…The late Charles M. Vest, president emeritus of the National Academy of Engineering and president emeritus of the Massachusetts Institute of Technology, concurred: “[Engineering] systems cannot be wisely envisioned, designed, or deployed without an understanding of society, culture, politics, economics, and communications—in other words, the very stuff of the liberal arts and also of the social sciences.”
Interesting that they add the 2nd "M" -- "Medicine." 

apropos, I've riffed on "The Art of Medicine" here before.

"Humanities?" See my cite of Dr. Rachel Pearson (MD, PhD in Medical Humanities).

See also my numerous cites of the eloquent, prolific MD writer Dr. Danielle Ofri.

I first cited this effort back in April (scroll down). By all means, subscribe and follow.


They gave me a comp review copy.

More to come...

Thursday, July 12, 2018

The Medical Record: Paper or Pixels?

"It doesn’t matter if you’re a patient, a doctor, a clinical coder or a CEO. It doesn’t matter if a patient’s medical record is paper or pixel, or whether it’s being lifted out of a box in a hospital basement or accessed from thousands of miles away via an app on a hospitalist’s smartphone. No matter how quickly you can get it, the information is of no use if it’s wrong."
Just came across an article on The Huffington Post by science writer Abby Norman:
‘Minor’ Errors In Medical Records Can Have Major Consequences
“Quality” is a buzzword in many industries ― but in health care, it’s lumped in with “safety,” since poor quality can lead to much more than just customer dissatisfaction.

Medical errors are the third leading cause of death in the U.S., according to Johns Hopkins University School of Medicine researchers: Each year, approximately 250,000 patients in the U.S. die due to such errors. But more often than not, medical errors hurt patients in unobvious ways, just as an illness doesn’t always present itself clearly and instead takes root perniciously, over time and under the radar. They’re a sign of a much more severe ailment that plagues our entire health care system.

One place these errors lurk is in documentation and medical records.

As long as people have been practicing medicine, they’ve been keeping records ― if only for the purpose of billing and not necessarily to facilitate continued and coordinated care. Today, medical documentation, whether paper or electronic, serves a number of purposes, facilitating billing and patient care and serving as evidence to help doctors avoid lawsuits (or help patients litigate). 

Though we’ve seen a major push in the last decade to digitize health information and make it more widely accessible to both providers and patients, dreams of the “shared electronic medical record” have been slow to come to fruition.

Why? Because providers and health care systems are being asked to switch to new technology, which requires an investment of finances and time. And if health care providers in this country are short on anything, it’s time…
Good article. Read all of it (linked in the title).


The debate rages on, as it has since I first came to do EHR work in 2005 under the QIO "DOQ-IT" initiative ("DOQ-IT" -- "Doctors' Office Quality - Information Technology.")

Based on my long experience (as an analyst, a HIT operative, and a patient), I can assert confidently that "paper is much slower" overall. The relative error rates, however, remain rather unclear -- and empirically complicated by the "shooting-at-a-moving-target" problem.

Beyond those issues, there's Margalit's beef: "Are structured data the enemy of health care quality?" Do digital "structured data" adversely impact the SOAP process?

Workflow efficiency and clinical cognition concerns aside, Abby Norman's piece is about health care data accuracy. Hmmm... what comes immediately to mind? Theranos, perhaps? Beyond that scandal, see my prior post "The upshot of dirty data."

"I was recently reviewing my own chart with a nurse before a routine appointment, only to be informed that at some point since I’d last reviewed my records, my chart had been altered to say I had eight sisters, all of whom were in good health. I don’t have any sisters."
Lordy Mercy. Again, read her entire HuffPo article.

Some earlier thoughts of mine going to "data forensics."


Haven't read this. Don't know that I will, but it looks very interesting. The Amazon blurb:

In the fall of 2010, Abby Norman's strong dancer's body dropped forty pounds and gray hairs began to sprout from her temples. She was repeatedly hospitalized in excruciating pain, but the doctors insisted it was a urinary tract infection and sent her home with antibiotics. Unable to get out of bed, much less attend class, Norman dropped out of college and embarked on what would become a years-long journey to discover what was wrong with her. It wasn't until she took matters into her own hands--securing a job in a hospital and educating herself over lunchtime reading in the medical library--that she found an accurate diagnosis of endometriosis.

In Ask Me About My Uterus, Norman describes what it was like to have her pain dismissed, to be told it was all in her head, only to be taken seriously when she was accompanied by a boyfriend who confirmed that her sexual performance was, indeed, compromised. Putting her own trials into a broader historical, sociocultural, and political context, Norman shows that women's bodies have long been the battleground of a never-ending war for power, control, medical knowledge, and truth. It's time to refute the belief that being a woman is a preexisting condition.
My late daughter Danielle was blown off and stonewalled by her new Primary (at Kaiser) for many months. Maybe she'd still be alive. Maybe not. I stew about it episodically.
More to come...

Monday, July 2, 2018

"Overcharged?" Paying for health care

The publisher (CATO Institute), at the request of one of the authors, graciously gave me a pre-pub comp copy to study and review. The book is to be released on July 3rd.

"Why is the American health care system so dysfunctional and expensive? Why does the EpiPen, containing $1 worth of medicine, cost $600? Why do hospitalized patients receive bills laden with inflated and surprise charges that come out of the blue from out-of-network providers, or that demand payment for services that weren't delivered? Why is more than $1 trillion―one out of every three dollars that passes through the system―lost to fraud, wasted on services that don't help patients, or misspent? What are the causes of spiraling costs, mediocre quality, and limited access?

Overcharged details how the answers to these questions are connected and reveals a system that performs as if it had been designed to spend as much money as it can, and to be as confusing and unfriendly as possible, with no accountability. Overcharged then exhaustively details real reforms―showing how health care can become more efficient and pro-consumer when it is subjected to the competitive forces that apply to the rest of the economy, and will only get better and cheaper when consumers exert pressure from below."
It's a serious (if partisan) book, deserving of serious study and critical analysis. A bargain at $7.99 Kindle price. I find in it much to both agree with and to be skeptical of.

I recently underwent a coronary angiogram px, dx preparatory to my upcoming SAVR px (open heart aortic valve replacement surgery). My "chargemaster" invoice and EoB statement numbers:
Cardiology:  $31,004.00
Laboratory:  $$615.84
Med/Surg Supplies & Devices:  $4,624.00
Pharmacy:  $1,391.20
Total:  $37,635.04
Medicare paid $2,667,29 (it's considered a Medicare Part-B outpatient encounter), my residual balance owed was $1,209.44, for a total paid of $3,876.73. Roughly 10.3% of the (BS) "retail."

I was there for about 4 hours, so, roughly a grand an hour, for all of that technology and expertise.

Did I "overpay" to comfortingly learn from my cardiologist that I "have the arteries of an 18 year old?"


Sometime in the next couple of months, a highly respected and experienced local cardiac surgeon and his team will sedate and anesthetize me, render me deeply unconscious, emplace a breathing tube in my throat, slice open my chest, spread out my rib cage, stop my heartbeat, put me on a heart-lung machine, cut my heart open, remove my seriously stenotic aortic valve, replace it with a sutured-in prosthetic (pig or bovine tissue) valve, close the heart back up and re-start it, close my chest back up, and send me off to Recovery.

One hopes.

The Healthcare Bluebook pegs the current "fair price" for the SAVR px in my area at about $90k.


Back to Overcharged. Per Covey, I "begin with the end in mind."
For the last half century, the chief object of American health policy has been to ensure that consumers pay the smallest possible fraction of the cost of medical care at the point at which treatments are delivered. Obamacare, the State Children’s Health Insurance Program, Medicare, Medicaid, the U.S. Veterans Health Administration (VHA), and tax-advantaged private insurance arrangements— along with the long list of coverage mandates that go with them— all reduce direct financial responsibility for medical services to a minimum. As explained in Chapter 15, the evil genius of third-party payment is that it encourages consumption and drives up costs by making medical services cheap for patients at the point of sale.

The public officials, insurers, and health care providers who benefit from all this spending defend third-party payment arrangements by arguing that health care is too complicated and too expensive for consumers to manage on their own, and by contending that people who are directly responsible for health care costs will use medical services less often than they should. Better that government bureaucrats spend tax dollars and that private insurers spend premium dollars, they argue, than that consumers pay for medical services themselves. They don’t want consumers to consider the possibility that market mechanisms might remediate excessive costs and complications as successfully in health care as they have in other sectors. This is to be expected. Widespread reliance on third-party payment arrangements benefits insurers and health care providers, so they want nothing to interfere with it…

…An abundance of evidence, including everything from peer-reviewed academic studies of the impact of Medicare and tax breaks on costs to news reports about surprise bills, retail outlets, and frauds, makes it clear that the politicized third-party payment system is the main culprit. Instead of expanding the reach of that system, as Obamacare did, we should face facts and start paying for health care the same way we pay for everything else. When hundreds of millions of people spend their own money on health care, they will behave differently, and health care providers will too. Consumers will look for services that offer better value for the dollar, and doctors, hospitals, drug companies, and other medical outlets will try to provide them. Prices will fall and both the availability and the quality of medical treatments will improve.

Many health care providers won’t like this new world in which they must compete for business. They benefit from existing arrangements, which pay them whatever they ask and send them more dollars year after year. We should stop indulging them, and we should stop listening to their apologists and lobbyists too. Markets do a good job of supplying food, clothing, housing, transportation, and other essentials. They can help us meet our needs for medical treatments.

One of the most wonderful things about markets is that they automatically reward sellers who treat consumers well and automatically punish those who don’t. Both the carrot and the stick are important. For American health care to improve, providers that deliver high-quality services at reasonable prices must be rewarded and inferior providers must fail. There must be turnover and opportunities for new entrants. A near-death experience made the American automobile industry more efficient and pro-consumer, and decades later, innovators like Tesla are still forcing existing manufacturers to do better by deploying new technologies and business models. If and when the businesses that operate in the American health care sector are subjected to intense competition, they will respond the same way. And if they don’t, they will fall by the wayside and new businesses will emerge that will offer Americans cheaper and better health care.

Change won’t come easily. Old-line health care companies have rigged the game in their favor. They benefit from a guaranteed flow of dollars and massive subsidies. They control market entry. And they have convinced the American public that they should not have to operate like other businesses…

Charles Silver & David A. Hyman. Overcharged: Why Americans Pay Too Much for Health Care (Kindle Locations 7253-7295). CATO Institute.
That is the crux of their argument.

Which begins thus:
The problems with America’s health care system are many and varied. That’s why there is no general guide to all of them. Instead, there are thousands of books and articles about specific difficulties, such as the mistreatment of prostate cancer in men, the politics of health care reform, outrageous hospital charges, or fraud in the prescription drug business.

Although many of these writings are excellent, they fail to convey a sense of the whole. An intelligent person wants to know, at the most general level, why our health care system is so dysfunctional. What are the root causes of spiraling costs, mediocre quality, and limited access? Why is more than $ 1 trillion— one out of every three dollars that passes through the system— lost to fraud, wasted on services that don’t help patients, or otherwise misspent? Why do hospitalized patients receive bills that are laden with inflated charges, that come out of the blue from out-of-network providers, or that demand payment for services that weren’t delivered? Why does the EpiPen, an old technology that contains $ 1 worth of medicine, cost $ 600? Do questions like these require separate answers? Or are the answers connected? Are there core drivers of the health care system’s many pathologies?

We believe that an array of the American health care system’s most important shortcomings stem from a few root causes. We also think that it is important to lay these fundamental drivers bare for everyone to see...
[ibid, Kindle Locations 43-53]
 Between these bounds lie 22 chapters fully laying out their argument and supporting evidence. to wit:
The United States is “the most expensive place in the world to get sick.” 1 Why? One big reason is that providers routinely game the payment system. Drug companies are experts at this. Chapter 1 describes how they first gain strangleholds on supply. Chapter 2 describes how they then charge whatever they want, knowing the payment system imposes no restraint on prices. Chapter 3 shows that shady conduct occurs at every point in the drug distribution chain and often involves the willing participation of pharmacists and physicians who profit by exploiting existing payment arrangements. It is easy to see why spending on prescription drugs, new and old, has gone through the roof.

Doctors game the payment system too. As Chapters 4 and 5 show, they deliver an ocean of services that patients don’t need, such as excessive numbers of stents and cesarean deliveries. Chapter 6 describes how doctors regularly perform treatments that haven’t been proven to work, many of which are found to be ineffective or harmful when they are finally studied with care.

Chapter 7 explains how public officials get in on the action. In return for sizable campaign contributions from health care providers and their lobbyists, they let the flow of cash into the health care sector continue and look for ways to increase it. When the campaign contributions are large enough, elected officials even go to bat for corrupt providers who face fraud investigations.

Some hospitals and doctors aren’t satisfied with excess payments for garden-variety overuse and unnecessary care, and they turn to a life of crime— or at least abuse. Chapter 8 explains how hospitals “upcode” treatments, invent secondary conditions that patients don’t have, and concoct phony bills. Chapter 9 shows how hospitals also conspire with doctors to maximize their revenues by capturing differences in payments based on the site of service, tacking on absurd charges, and gouging patients who are uninsured or treated by out-of-network physicians at their facilities. Chapter 10 describes how hospices, nursing homes, and home health care services play similar games and frequently charge for services that were never delivered.

Chapter 11 shows how some doctors operate pill mills that supply the street with dangerous drugs— likely contributing to the rising death toll from overuse of prescription narcotics. Ambulance companies and durable medical equipment suppliers cheat the system regularly too, as do domestic and international criminal gangs. As Chapter 12 explains, there are far too many malefactors for the police to catch. For every one police put away, two more pop up. That is why the same types of fraud succeed again and again and again.

Chapter 13 explains that the quality of health care is often dangerously low because the payment system pays providers regardless of how well or poorly their patients fare. In fact, it often doles out more money to providers when patients experience complications than when they get well. Chapter 14 explains how incumbent health care providers have stifled competition so successfully that the government has to pay them extra to improve. In other industries, competition forces existing business to bear the costs of improving their products.

Although there have been repeated attempts to address these problems, all have failed because they have not changed the core incentives driving the system. We address that problem in Part 2...
[ibid, Kindle Locations 542-570]
And so on.

I found this interesting:
Academic research on health care, of which there is an enormous amount, presented other challenges. In a book of this type, which is intended to provide a coherent, high-level account of the entire health care system for a general audience of intelligent readers, we can discuss only general themes and the leading works that develop them. And we cannot go into even those works in much detail. We therefore strove to set out the basic insights and most important findings, and to do not much more than that. Readers who want to read the literature in greater depth are welcome to begin their journey by using the many citations we provide. [ibid, Kindle Locations 95-100]
Candidate Trump: "You're going to have such great health care, at a tiny fraction of the cost, and it's going to be so easy."

President Trump: "Who knew health care could be so complicated?"

I am reminded of a number of other health care policy writings I've studied across the years,
beginning with my 1994 grad school "argument analysis and evaluation" semester paper of the JAMA Single Payer proposal article (pdf). More on that paper here.

More stuff:

Ugliest book cover "art" ever. See this post.


And, multiple cites of Einer Elhauge -- the "Allocating health care morally" guy (pdf).
Health law policy suffers from an identifiable pathology. The pathology is not that it employs four different paradigms for how decisions to allocate resources should be made: the market paradigm, the professional paradigm, the moral paradigm, and the political paradigm. The pathology is that, rather than coordinate these decisionmaking paradigms, health law policy employs them inconsistently, such that the combination operates at cross-purposes. 

This inconsistency results in part because, intellectually, health care law borrows haphazardly from other fields of law, each of which has its own internally coherent conceptual logic, but which in combination results in an incoherent legal framework and perverse incentive structures. In other words, health care law has not-at least not yet-established itself to be a field of law with its own coherent conceptual logic, as opposed to a collection of issues and cases from other legal fields connected only by the happenstance that they all involve patients and health care providers. 

In other part, the pathology results because the various scholarly disciplines focus excessively on their favorite paradigms. Scholars operating in the disciplines of economics, medicine, political science, and philosophy each tend to assume that their discipline offers a privileged perspective. This leads them either to press their favored paradigm too far or to conceptualize policy issues solely in terms of what their paradigm can and cannot solve.
Instead, health law policy issues should be conceived in terms of comparative paradigm analysis. Such analysis focuses on the strengths and weaknesses of the various decisionmaking paradigms, determining which is relatively better suited to resolving various decisions, and then assigning each paradigm to the roles for which it is best suited. It is from this comparative perspective that this Article analyzes the promise and limits of the moral paradigm for allocating health care resources…
I have more cites, but those are enough for these purposes. Again, a macro-level health econ policy SME I'm not. My relative expertise, as I've noted before, is principally limited to domains such as InfoTech, workflow/process QI (big-time Lean advocate), and HIPAA.

We rightfully expect (and get) continuous improvements in health care / bio-med technology. We know dispositively that scientific process QI methods such as Lean continue to bear significant fruit (notwithstanding being confined within a chaotic health care economic environment). Were we to apply such methodical "customer-value-add" thinking to the administrative / financial side, what might we accomplish? Is the only way to get there removal of payor intermediaries?
Defining "customers" is a significant sand-in-the-gears obstacle, I know. So many "stakeholders" (as the authors and numerous others point out) beyond patients, many of them with inordinate incumbent market clout -- abetted by (margin-correlated) opacity and barriers to entry.
  • I have long irascibly asserted that "no amount of calling 3rd-party (mostly for-profit) intermediated, dubious value-add pre-payment plans 'insurance' will make them so." These authors give that assertion a good confirmatory airing. Insurance is properly a risk-vetted hedge against catastrophic loss. It maked me crazy that so many don't get this.;
  • I have abiding skepticism that the (conflated phrase) "free markets" comprise a uniformly beneficent way to structure socioeconomics. For one thing, let's not confuse "private markets" with "free markets." All human activity gets regulated one way or another. On this point, Google "Gresham's Dynamic." Anyone still recall the 2008 financial crash? Central to the argument here is that assertion here is that the health care space is "just another consumer market" and will function optimally without "government meddling." I have serious skepticism that a direct-cash-pay price for my upcoming heart surgery would be materially less than the ~$90k Bluebook "fair price" any time soon -- and all I have at this point is "soon.";
  • Also in that regard, the authors recommend that people might "finance" big-ticket acute care encounters beyond their cash-on-hand means (such as, e.g., say, my pending SAVR px -- though I actually, luckily could pay for it OoP). What could possibly go wrong there? As someone who did a lengthy stint in subprime risk management, I have some views on that idea. (apropos, not too long ago, at WinterTech, some VCs were speaking of indeed looking at opportunities in the private "medical financing space.");
  • The authors tout the potential of "medical tourism." Interesting. I seriously looked at going to Germany or Switzerland to pay cash for a "TAVR" px rather than the open-heart valve job I've decided on; 
  • Two dozen cites regarding "EHRs," almost all of them negative (largely re: "Meaningful Use" so despised by "conservatives");
  • "Singapore" as an exemplar? Seriously? Dunno; never been there. Neither have I been to Scandinavia (often cited as universal coverage successes), in fairness;
  • Really didn't care much for the "intergenerational 'warfare' / reverse Robin Hood" assertions. Is a "commonwealth" really only legitimate within the confines of short-term transactionalism?
  • When did it become a "conservative" idea to simply give people "vouchers" via which to buy private market health care? (Or, "school choice," etc?). Central to the CATO Liturgy is that "subsidies distort markets." And, yeah, lots of truth there broadly. The "benefit" of my home mortgage deductability has to be (invisibly) baked into the house's "market value." It has to really be a net wash;
  • But, tangentially related to the foregoing point, the writers cite the comparative examples of Social Security vs, Medicare. I'm am now a Social Security and Medicare bene. I get a fixed SS amount each month, and it's up to me to decide how to spend it. Overcharged posits that Medicare should be no different. Any problems there? 'eh?
I find the authors' assessment of the core dysfunctions of our "fragmented" health care "system" rather spot-on (a lot of it is not exactly news to me; see my other book cites, and prior postings). Nonetheless, I have to have concerns about the broad ("equal access") viability of their proposed "market solutions." But, I'm still burrowed deep in the book -- which I heartily recommend, irrespective of your policy positions. More as this Grasshopper learns more.

I'd love to have reactions from my pal, medical economist J.D. Kleinke on this stuff.


Do poor people have a right to health care?
NY Times Editorial Board

The 16 Kentuckians who recently won a lawsuit challenging the legality of Medicaid work requirements include a law student with a rare heart condition, a mortician with diabetes, a mother of four with congenital hip dysplasia and a housekeeper with rheumatoid arthritis. It’s a mixed bunch, united by two grim facts: They live at or below the federal poverty level, and they’re caught in the cross hairs of a debate over what society owes its neediest members.

Their lawsuit argued that insisting that people work a certain number of hours a month in order to receive Medicaid benefits, like other requirements the state was planning to demand, is illegal because it runs counter to Medicaid’s purpose — to ensure that low-income people have access to decent care. The lawsuit also contended that such requirements would imperil the plaintiffs’ health by depriving them of the only medical insurance they could afford. The new rules, which would have stripped recipients of their benefits if they failed to meet monthly hours-worked quotas and strict reporting standards, were simply oblivious to the realities of low-wage living in Kentucky, and America in general…

…the latest salvo in a protracted national reckoning over Medicaid, a program that has been in place for more than half a century and now insures one in five Americans, or roughly 74 million people. In January, the federal government announced that it would reverse decades of precedent and allow states to tie Medicaid coverage to work requirements. The move is part of a wider conservative-led campaign to restrict the number of people who benefit from social safety-net programs. It also reflects persistent national ambivalence over the question of whether health care is a human right or an earned privilege — and, if the latter, how “earned” should be defined…

…the basic ideological argument for work requirements — that people should earn their government benefits — collapses under scrutiny. Numerous analyses have indicated that a clear majority of Medicaid recipients who can work already do work. Of the 9.8 million working-age Medicaid recipients who are not employed, the vast majority have physical limitations or provide full-time care to young or elderly family members; just 588,000 of them are able to hold jobs but are currently unemployed, according to a 2017 report. And most of those are actively looking for work…

…it would seem that the Trump administration’s push to enact work requirements is aimed not at improving health, or even at cutting costs — there are more effective ways to do both — but rather at stigmatizing Medicaid, a program that has become less maligned in recent years, as more Americans have become insured under it. In one 2017 poll, 74 percent of respondents said they had a favorable view of Medicaid.

But while most Americans agree that poor people should have health insurance, they also believe that people of all income levels should earn their benefits — the same poll from last year found that 70 percent of respondents supported Medicaid work requirements. That paradox, of increasing support for Medicaid amid lingering suspicion toward Medicaid recipients, underscores persistent questions about how Americans view those in need…
"[O]ne peculiarity of our present climate is that we care much more about our rights than about our 'good'."  -- Simon Blackburn, Being Good

And, a chronic difficulty lies in determining where the two are not mutually exclusive, no?


From STATnews: "As Atul Gawande steps into a risky health CEO role, here are five challenges he faces."

Notes many of the same issues as Overcharged.
Modern Healthcare, July 11th:
Is private equity helping or hurting healthcare?
By Harry Gamble  | July 10, 2018

Some view third-party investment in physician practices as a vital trend that offers economies of scale that make healthcare more efficient. Others believe it fosters monopoly control while driving up prices. But nearly everyone agrees that further consolidation within the U.S. healthcare market is coming.

The Chicago-based American Medical Association is in the midst of a yearlong effort to quantify the impact that venture capitalists, private equity firms and other outside entities have on the way doctors treat their patients. The study rolls on as the number of physicians who work for themselves continues to shrink. According to a report by Accenture, the share of U.S doctors in independent practice has plummeted to 33 percent in 2016 from 57 percent in 2000.

"The days of Marcus Welby are behind us," said Anthony LoSasso, professor of health policy and administration at the University of Illinois at Chicago's School of Public Health. "The uncertainty over healthcare policy in Washington is probably driving the integrated healthcare delivery systems and large hospitals to bulk up almost as a counterweight to the uncertainty they face. They know that if you are bigger, you are in a better position to survive whatever may come your way.”…

More to come...